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Mellss surgery y3 intestinal obstruction


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intestinal obstruction

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Mellss surgery y3 intestinal obstruction

  1. 1. Amalina Aminuddin 082012100067
  2. 2.  Clinical features  Imaging  Treatment of acute intestinal obstruction INTRODUCTION
  3. 3. Vary according to : • Location of obstruction • Age of obstruction • Presence or absence of intestinal ischemia • Underlying pathology Classic quartet : • pain, distension, vomiting and absolute constipation CLINICAL FEATURES OF DYNAMIC OBSTRUCTION
  4. 4. Based on location of obstruction: • Small bowel •High : minimal distension ,early ,profuse vomiting , rapid dehydration, little evidence of fluid level •Low : central distension with pain, delayed vomiting, multiple central fluid level • Large bowel :pronounced distension, mild pain, late vomiting and dehydration, proximal colon and caecum distended CLINICAL FEATURES
  5. 5. Based on duration of obstruction: • Acute •Sudden severe central abdominal pain, distension, early vomiting and constipation • Chronic •Lower abdominal pain, constipation followed by distension • Acute on chronic •Short history of distension and vomiting against a background of pain and constipation • Subacute CLINICAL FEATURES
  6. 6. Pain •Sudden, severe •Colicky  mild, constant diffuse pain •On umbilicus or lower abdomen •Not significant in paralytic ileus Vomiting •Appear late in distal obstruction •Digested food  faeculent material CLINICAL FEATURES
  7. 7. Distension •SI: Increases the more distal •LI: Delayed Constipation •Absolute or relative •Does not apply in •Richter’s hernia, •Gallstone obstruction, •Mesentric vascular occlusion, •Associated with pelvic abscess
  8. 8. • Dehydration • In SI obstruction • Dry skin and tongue, sunken eyes, oliguria • Hypokalemia • Associated with strangulation • Pyrexia • Indicate ischemic onset, intestinal perforation or inflammation • Hypothermia • Septicaemic shock • Abdominal tenderness • Local – ischemia • Generalised – infarction or perforation
  9. 9. • Constant pain • Local tenderness with rigidity • rebound tenderness (Blumberg’s sign). • Shock • Occur suddenly and recur regularly • Hernia: • tense, tender, irreducible, no expansile cough and increased size CLINICAL FEATURES OF STRANGULATION
  10. 10. Episodes of screaming and drawing up of legs For a few minutes and recur Vomiting Redcurrant jelly stool Sausage- shaped lump Sign of Dance CLINICAL FEATURES OF INTUSSUSCEPTION
  11. 11. PR-  blood- stained mucus  Palpable or protruding apex Dehydration, distension, peritonitis Differential diagnosis  Acute gastroenteritis  Henosh- Schoenlein purpura  Rectal prolapse
  12. 12. Volvulus of small intestine Lower ileum Primary or secondary Caecal volvulus May be congenital More in females Palpable tympanic swelling in midline or left Sigmoid volvulus Intermittent symptoms followed by passage of large quantities of flatus and feces Early progressive abdominal distension, hiccough, retching, late vomiting, constipation CLINICAL FEATURES OF VOLVULUS
  13. 13. Erect and supine abdominal films • Jejunum: valvulae conniventes ( concertina effect) IMAGING
  14. 14. •Ileum: featureless •Large bowel : haustral folds • Caecum: rounded gas shadow in right iliac fossa
  15. 15. Fluid levels • Prominent on erect film • Physiological: at duodenal cap and terminal ileum • More in distal small bowel obstruction • May have in high large bowel obstruction, paralytic ileus or pseudo-obstruction • Seen in IBD, acute pancreatitis and intra- abdominal sepsis
  16. 16. •Gallstone ileus: gas in biliary tree with stones • Large bowel obstruction: large amount of gas in caecum
  17. 17. INTUSSUSCEPTION  Ileocaecal intussusception  Absent caecal gas shadow  Claw sign with barium enema  Doughnut appearance on USG abdomen IMAGING IN
  18. 18. VOLVULUS  Caecal volvulus:  Gas-filled ileum and distended caecum  Bird beak deformity with barium enema  Sigmoid volvulus:  Massive colonic distension  Dilated loop running diagonally from right to left with one fluid level within each loop  Volvulus neonatorium:  Normal or duodenal obstruction  gasless
  19. 19. Measures to treat acute intestinal obstruction i. Gastrointestinal drainage ii. Fluid and electrolyte replacement iii. Relief of obstruction iv. Surgical treatment Principles of surgical intervention  Management of:  The segment at site of obstruction  The distended proximal bowel  The underlying cause of obstruction TREATMENT OF ACUTE INTESTINAL OBSTRUCTION
  20. 20. i. Gastrointestinal drainage/Nasogastric decompression  passage of a non-vented (Ryle) or vented (Salem) tube  4-hourly aspiration, continuous or intermittent suction ii. Fluid and electrolyte replacement  Hartmann’s solution or normal saline iii. Antibiotic therapy  mandatory for patients undergoing surgery SUPPORTIVE MANAGEMENT
  21. 21. Indications for early surgical intervention: • Obstructed/strangulated external hernia • intestinal strangulation • Acute obstruction Indication for delay in surgical intervention: • Complete obstruction with no evidence of intestinal ischemia • delayed until resuscitation is complete. • Obstruction secondary to adhesion without pain or tenderness • Conservative management up to 72 hours SURGICAL TREATMENT
  22. 22. • Adequate exposure is best achieved by midline incision • Assessment is directed at : • Site of obstruction • Cause of the obstruction • Viability of the gut
  23. 23. Caecum  Collapsed: small bowel obstruction  Dilated: large bowel obstruction To display cause of obstruction:  Displace small bowel loops and cover with warm moist abdominal packs  Operative decompression  If dilatation of loop prevent exposure  Viability of gut is threaten  Closure is compromised 1) ASSESSMENT OF SITE
  24. 24. Can be done by:  Savage’s decompressor within a purse-string suture  Nasogastric tube  Milking the content retrogradely to stomach OPERATIVE DECOMPRESSION
  25. 25.  Determine the type of surgical procedure  Enterolysis  Excision  Bypass  Proximal decompression 2)ASSESSMENT OF CAUSE
  26. 26. 3)ASSESSMENT OF VIABILITY VIABLE INTESTINE NON-VIABLE INTESTINE Circulation • Dark colour becomes lighter • Dark colour remains • Visible pulsation • No Peritoneum • Shiny • Dull and lustreless Musculature • Firm • Flabby, thin and friable • Peristalsis may be observed • No peristalsis • May have pressure rings • Persist pressure rings
  27. 27.  Infarcted gut are resected.  If viability of gut is in doubt:  Wrap bowel in hot packs for 10 minutes with increased oxygenation and reassessed.  Resected: raise both ends of the bowel as stomas  No resection/ multiple ischemic areas: laparatomy at 24-48 hours  Note the site of resection, length of resected and residual bowel
  28. 28.  Bailey & Love’s Short Practice of Surgery, 26th Edition.  html  Film-++Differentiating+Large+and+Small+Bowel  REFERANCE